Job Description
The Utilization Management Nurse (UMN) collaborates closely with the interdisciplinary team to perform reviews of service authorization requests, ensuring the utilization of appropriate services. The UMN assists in complex cases, develops internal processes, and educates physicians on utilization review issues. The role involves managing continuity of care, ensuring smooth transitions, patient satisfaction, safety, and appropriate length of stay.
ResponsibilitiesReview prior authorization requests for medical necessity and appropriateness using standardized Review Criteria.Coordinate with the Medical Director/Physicians for requests outside standard Review Criteria.Maintain compliance with federal and state guidelines as well as contractual requirements.Obtain necessary documentation and ensure completion of assigned caseload.Serve as a liaison between the Medical Director, physicians, and office staff to resolve authorization issues.Communicate denial determinations to providers when indicated.Perform evaluation and concurrent monitoring of appropriate utilization of resources.Provide timely documentation reflecting department work processes and policy guidelines.Promote safe and appropriate coordination of care and optimal utilization of resources.Identify and participate in developing programs, policies, and procedures for continuous quality improvement.Ensure adherence to company and department policies regarding confidentiality.Participate in regular departmental training.Serve as a plan liaison to coordinate enrollee benefits with providers and/or external organizations.Prepare and present reports on department activities as assigned.Essential SkillsClinical reviewUtilization reviewUtilization managementInterQualMilliman Commercial GuidelinesMedicaidMedical managementMedicareManaged carePatient careMedical recordCase managementConcurrent reviewDischarge planningMedicalAcute careAdditional Skills & QualificationsCurrent unrestricted Florida RN or LPN License.Minimum of one year of utilization review experience.Minimum of one year of experience in discharge planning in an acute care setting highly desirable.Four years of related clinical experience in a healthcare field; or equivalent combination of education and experience.Valid Florida Driver’s License.Knowledge of case management and utilization review concepts, including InterQual and Milliman Criteria.Knowledge of Florida Medicaid Program and CMS Guidelines.Proficient in word processing software, spreadsheet software such as Microsoft Excel, and electronic medical record software.Work Environment
This position offers a hybrid work schedule, with in-office work in Sunrise on Tuesdays from 8:30 AM to 5:00 PM, including a 30-minute lunch. Training will take between 2-4 weeks, with opportunities to shadow team members onsite and through Teams.
Pay and Benefits
The pay range for this position is $35.00 - $38.00/hr.
Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:
• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)
Workplace Type
This is a hybrid position in Sunrise,FL.
Application Deadline
This position is anticipated to close on Jun 30, 2025.
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.